Divisional RN Care Navigator - North Carolina or Virginia

About the position Responsibilities • Conduct Transitions of Care Management for a subset of the patient population, including ER and hospital follow-ups. • Provide triage guidance and supportive consultation to other team members, handling escalated complex cases. • Develop care plans leveraging the 5Ms Geriatric best practice framework. • Develop a holistic view of patient needs related to Social Determinants of Health. • Identify existing barriers to engagement with necessary resources and supports. • Provide education around maintenance of chronic health conditions, as well as available options for behavioral care and social support. • Serve as liaison between the patient and the direct care providers, assisting in navigating both internal and external systems. • Initiate care planning and subsequent action steps for high-risk members, coordinating with the interdisciplinary team. • Support patients' self-determination, motivating patients to meet the health goals they have identified. • Refer patients to necessary services and supports, including assistance with transportation, food insecurity, and benefit applications. • Lead Interdisciplinary Team Meetings when indicated. • Assess patient's family system and conduct family meetings with patient and family when needed. • Participate in the creation and facilitation of team training content. • Conduct group psychoeducation and support groups within the Center. • Perform all other duties and responsibilities as required. • Participate in and lead interdisciplinary review of and coordination around complex patients. • Maintain patient confidentiality in accordance with HIPAA. • Document patient encounters in the medical record system in a timely manner. • Follow general policies related to fire safety, infection control, and attendance. Requirements • Registered Nurse (RN license) with NC or VA or Compact. • Minimum of 4 years of experience working in human services and navigating community-based resources. Nice-to-haves • Familiarity with state Medicaid guidelines and application processes. • Experience working with patients with behavioral health conditions and substance use disorders. • Prior experience conducting home visits and knowledge of field safety practices. Benefits • Medical, dental, and vision benefits. • 401(k) retirement savings plan. • Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave. • Short-term and long-term disability. • Life insurance. Apply tot his job